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Garcia, Nehemiah B. BSN 2Y2-2A: Ncma 219 Lec Course Task # 5

The patient is experiencing symptoms of preeclampsia including headache, swelling, and abdominal pain. On assessment, the patient has a blood pressure of 140/90, trace protein in her urine, and weight gain of 2 lbs per week in the second trimester and 1 lb per week in the third trimester. The nurse's diagnosis is pregnancy induced hypertension, likely caused by fluid retention due to preeclampsia. The nurse's plan is to educate the patient and family on monitoring, engage the patient in a therapeutic regimen of monitoring weight, blood pressure, urine protein and edema to prevent complications of preeclampsia for both mother and baby.

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46 views2 pages

Garcia, Nehemiah B. BSN 2Y2-2A: Ncma 219 Lec Course Task # 5

The patient is experiencing symptoms of preeclampsia including headache, swelling, and abdominal pain. On assessment, the patient has a blood pressure of 140/90, trace protein in her urine, and weight gain of 2 lbs per week in the second trimester and 1 lb per week in the third trimester. The nurse's diagnosis is pregnancy induced hypertension, likely caused by fluid retention due to preeclampsia. The nurse's plan is to educate the patient and family on monitoring, engage the patient in a therapeutic regimen of monitoring weight, blood pressure, urine protein and edema to prevent complications of preeclampsia for both mother and baby.

Uploaded by

Mushy_aya
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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OUR LADY OF FATIMA UNIVERSITY

CABANATUAN CAMPUS
COLLEGE OF NURSING

Garcia, Nehemiah B.
BSN 2Y2- 2A

NCMA 219 LEC

Course Task # 5

ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION EVALUATION


SUBJECTIVE: Deficient The condition After the nursing  Educate patient and After the nursing
“Napasin ko nitong fluid volume is possibly intervention patient will : family members or intervention patient was:
mga nakaraang related to caused by significant others on
araw na lagang fluid loss to What we call  engage in home  Engaging in
masakit ang ulo ko , subcutaneous a pregnancy therapeutic monitoring/day-care therapeutic
pansin ko din na tissue induced regimen and program, as regimen and
parang tumataba hypertension monitoring, as appropriate. monitoring as
ako , at tsaka — is defined indicated.  Weigh the patient indicated.
minsan sumasakit by high  verbalizes regularly. Tell  Was able to
din yung sikmura blood understanding of patient to record verbalize the
ko” verbalized by pressure and need for close weight at home in understandingof
the patient. excess protein monitoring of between visits. need fro close
in the weight, BP, urine  Differentiate monitoring of her
OBJECTIVE: urine after 20 protein, and physiological and weight, BP, urine
 BP of weeks edema. pathological edema protein, and
140/90 of pregnancy.  Patient is free of of pregnancy. Locate edema
 1+ to 2+ Often, signs of and determine  Patient has been
OUR LADY OF FATIMA UNIVERSITY
CABANATUAN CAMPUS
COLLEGE OF NURSING

proteinuria preeclampsia generalized degree of pitting. free of signs of


on random causes edema (i.e.,  Note signs of generalized
 weight gain only modest epigastric pain, progressive or edema (i.e.,
of 2 lbs per increases in cerebral excessive edema i.e., epigastric pain,
week on blood symptoms, epigastric/RUQ pain, cerebral
the 2nd pressure. Left dyspnea, cerebral symptoms,
trimester untreated, nausea/vomiting) symptoms, nausea, dyspnea,
and 1 lb per however, vomiting). Assess for nausea/vomiting)
week on preeclampsia possible eclampsia.
the 3rd can  Check on dietary
trimester lead to serious intake of proteins
 Slight — and calories. Give
edema in even fatal — information as
upper complications needed.
extremities for
both mother  Monitor intake and
and face
and output. Note urine
bab color, and measure
specific gravity as
indicated.

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